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Recurrent peptic ulcers

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Abstract

This article is concerned mainly with recurrent ulceration (RU) after vagotomy [truncal (TV), selective (SV), or highly selective (HSV)]. RU may be symptomatic or asymptomatic. Since few surgeons routinely perform endoscopy on asymptomatic patients, it is symptomatic RU that is being discussed.

After all 3 types of vagotomy, without antrectomy, median incidences of RU are about 10% after 5–10 years, but there is wide variation, from 1% to 30%. There is no convincing evidence that TV denervates the parietal cell mass more effectively than does SV or HSV, or that it has a lower incidence of RU than SV or HSV. Claims that SV and HSV lead to fewer incomplete vagotomies and less RU than TV are, however, not convincing. Since SV + P (pyloroplasty) or gastrojejunostomy (GJ) carries the same risk of RU as HSV, but has more side effects because of loss of the pylorus, it has been abandoned. The choice of elective operation for duodenal ulcer (DU) thus lies among TV + D (truncal vagotomy + drainage procedure), HSV, and V + A (vagotomy + antrectomy).

The results of 5 controlled trials suggest that HSV yields better overall clinical results than V + A, even though the incidence of RU is 1% after V + A compared with 10% after HSV. Even for patients with hypersecretion of acid, V + A should not be employed in preference to HSV, because incidences of RU after HSV are no higher among hypersecretors of acid than among normal secretors. Gastrin cell (G-cell) hyperplasia and “antral dominance” are concepts still too nebulous to influence the choice of elective operation for DU.

After complete vagotomy (TV, SV, or HSV), as shown by the Burge, Grassi, or Hollander tests, the incidence of RU is 2–5%. High incidences of RU are not related to any characteristic of the patient, the level of acid output, or the ulcer, but are related to the surgeon who operates. They are thus related to operative technique, and are preventable.

Despite the advent of H 2-receptor antagonists, elective vagotomy (preferably in the form of HSV) still has a place in the management of DU because it is more effective than H 2-blockers in lowering intragastric acidity permanently and in preventing recurrent ulceration.

Résumé

Cet article est consacré principalement à la récidive ulcéreuse (RU) après vagotomie [tronculaire (VT), vagotomie sélective (VS), vagotomie hautement sélective (VHS)]. La récidive ulcéreuse peut Être symptomatique ou asymptomatique. En raison du fait que peu de chirurgiens pratiquent systématiquement l'exploration endoscopique, c'est la récidive ulcéreuse symptomatique qui a été prise en considération.

Après les 3 variétés de vagotomie, sans antrectomie, la fréquence moyenne de récidive ulcéreuse après 5 ans est d'environ 10% avec une large variation allant de 1% à 30%. Aucun fait convaincant ne démontre que la VT dénerve plus efficacement la masse cellulaire pariétale que la VS ou la VHS et que la récidive ulcéreuse est alors moindre. Cependant les affirmations selon lesquelles la VS et la VHS aboutissent à un taux plus bas de vagotomies incomplètes et un taux plus bas de récidives ulcéreuses, ne sont pas convaicantes. Par ailleurs, du fait que la VS associée à une pyloroplastie ou à une gastrojéjunostomie comporte le mÊme risque de récidive que la VHS mais qu'elle présente en outre des effets secondaires nocifs consécutifs à la perte de la fonction pylorique, cette méthode a été abandonnée.

Plusieurs groupes contrôlés de résultats à 5 ans suggèrent que la VHS donne au total de meilleurs résultats cliniques que la vagotomie associée à l'antrectomie et ceci en dépit du fait que le taux de récidive est de 1% après V + A alors qu'il est de 10% après VHS. MÊme chez les malades qui présentent une hypersécrétion acide la V + A ne doit pas Être utilisée de préférence à la VHS car la fréquence de la récidive ulcéreuse après la VHS n'est pas plus élevée chez les malades hypersécrétants que chez les sujets dont la sécrétion est normale. L'hyperplasie des cellules G et la dominante antrale sont des concepts encore trop incertains pour qu'il soient pris en considération dans le choix de l'intervention.

Après vagotomie complète (VT, VS, ou VHS) démontrée par les tests de Burge, de Grassi, ou de Hollander, la fréquence de la récidive ulcéreuse est de 2 à 5%. Le taux élevé de récidive ulcéreuse n'est pas le fait de facteurs inhérents au malade, au débit acide ou à l'ulcère; il correspond en réalité aux qualités du chirurgien, en un mot il dépend de la qualité de la technique opératoire. Il est donc possible de prévenir la RU.

Malgré l'avènement des anti-H2 la VS (la VHS en particulier) garde une place dans le traitement de l'ulcère duodénal car elle est plus efficace que ces agents du fait qu'elle abaisse en permanence l'acidité intra-gastrique et prévient ainsi la récidive de l'ulcère.

Resumen

Este artículo se refiere principalmente a la ulceratión recurrente (UR) después de vagotomía [troncular (VT), selectiva (VS), o altamente selectiva (VAS)]. La UR puede ser sintomática o asintomática. Puesto que muy pocos cirujanos realizan endoscopia rutinaria de pacientes asintomáticos, la discusión se limita a la UR sintomática.

Después de los 3 tipos de vagotomía, sin antrectomía, la incidencia promedio de UR es de alrededor de 10% a los 5–10 años, pero se observa una gran variación, con tasas de 1% a 30%. No existe evidencia de que la VT logre la denervación de la masa celular parietal en forma más efectiva de lo que lo hace la VS o la VAS, ni de que exhiba una menor incidencia de UR. Además, las pretensiones de que la VS o la VAS se acompañan de menores tasas de vagotomía incompleta y menos UR que la VT, no son tampoco convincentes. Puesto que la VS + P o GY implica el mismo riesgo de UR que la VAS pero tiene más efectos colaterales debido a la péridida del píloro, ha sido abandonada. La escogencia de una operación electiva para UD se halla entre VT + D (drenaje), VAS, y V + A (antrectomía).

Los resultados de 5 estudios controlados sugieren que la VAS produce mejores resultados clínicos globales que la V + A, aunque la incidencia de UR es de 1% después de V + A en comparación con 10% después de VAS. Aun en pacientes con hipersecreción de ácido, la V + A no debe ser empleada en preferencia sobre la VAS puesto que las tasas de UR después de VAS no son mayores en los hipersecretores de ácido que en los normosecretores. La hiperplasia de células G y la “dominancia antral” son conceptos todavía muy nebulosos para que puedan influenciar la escogencia de la operación electiva para UD.

Después de una vagotomía completa (VT, VS, o VAS), demostrado por las pruebas de Burge, Grassi, o de Hollander, la incidencia de UR es de 2–5%. Las altas incidencias de UR no se relacionan con característica alguna del paciente, con la producción de ácido o con su Úlcera, sino con el cirujano que realiza la operación. Se correlacionan con la técnica operatoria y, por lo tanto, son previsibles.

A pesar del advenimiento de los antagonistas de receptores H2, la vagotomía electiva (preferencialmente en forma de VAS) todavía posée un lugar en el manejo de UD, porque es más efectiva que los bloqueadores H2 en la reducción permanente de la acidez intragástrica y en la prevención de ulceración recurrente.

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  1. University Department of Surgery, The General Infirmary, Leeds, UK

    David Johnston Ch.M., F.R.C.S. & Richard L. Blackett F.R.C.S.

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Johnston, D., Blackett, R.L. Recurrent peptic ulcers. World J. Surg. 11, 274–282 (1987). https://doi.org/10.1007/BF01658103

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